Regency at the Park

Inspectors wroteBased on observation, interview, and record review the facility failed to promote resident dignity during mealtime in the dining room for 3 of 8 residents (Resident 70. 28 and 74) reviewed for dignity. Resident 70 had their medical information discussed while eating their meal and Resident's 28 and 74 were referred to by pet names. This failure placed residents at risk for embarrassment and a poor quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were evaluated, assessed, and physician orders were obtained for safe self-administration of medication for 1 of 3 residents (Resident 10), reviewed for self-medication administration. This failure placed residents at risk for inaccurate and unsafe medication administration, adverse side effects, and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to provide copies personal medical records, as required, to 1 of 2 resident (Resident 27), reviewed for resident rights. This failed practice placed residents at risk of not having access to their complete medical history, potential emotional stress affecting their ability to make informed decisions about their care, and a violation of their resident's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive person-centered care plans to address vision impairments for 2 of 3 Residents (Resident 42 and 76 ) reviewed for care plan development. This failure placed the residents at risk for unmet care and/or safety needs related to inaccurate or inadequate direction to staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary adaptive equipment for residents with highly impaired vision to maintain the highest practicable level of independence for 1 of 4 residents (Resident 42) reviewed for Activities of Daily Living (ADL's). This failure placed residents at risk for decreased nutritional intake, weight loss and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently document post dialysis (a treatment to filter wastes and water from the blood) assessments for 1 of 2 resident (Resident 6 and 22) reviewed for dialysis. This failure placed the resident at risk for unmet care needs and a potential for medical complications.

Inspectors wroteBased on interview and record review, the facility failed to develop and maintain a current hospice (a type of care that focuses on comfort and quality of life for people who were terminally ill or near the end of their life) care plan in collaboration with contracted hospice services, that identified what provider was responsible for performing specific services/functions for 1 of 2 sampled residents (Resident 24 ) reviewed for hospice services. This failure placed residents at risk for not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP, [a type of isolation used to prevent spread of infections]) for three of five residents (Resident 6, 31, and 76) reviewed for infection control. Ensure hand hygiene was performed and ensure proper use of Personal Protective Equipment (PPE) during daily resident cares and wound care treatment. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions and provide adequate supervision to prevent avoidable accidents during mechanical lift transfers for 2 of 2 residents (Residents 30 and 7) reviewed for falls. Resident 30 experienced harm when they fell from a mechanical lift while being transferred without the two-caregiver assistance as care planned onto their surgical incision site from their recent right below the knee amputation (BKA) requiring a transfer to the emergency room, surgical repair, and a five-day hospital stay. Resident 7 experienced an avoidable fall when left alone in their wheelchair after staff applied a mechanical lift sling under the resident and attached the sling to the mechanical lift. This failure placed the residents at risk for injury, pain, and recurrent falls.

Inspectors wroteBased on observation, interview and record review the facility failed to allow 6 of 6 residents (Residents 20, 12, 8, 56, 35, and 40) reviewed for resident rights, the right to self-determination to hold resident council meetings at the times of their choice and to discuss topics that were important to them such as dining and food choice issues. The failure to accommodate and address their right to make choices about important issues in their lives, placed the residents at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable and homelike environment when residents were served and ate off the plate still on the delivery tray in 2 of 2 dining rooms (900-unit and subacute dining rooms), reviewed for dining services. This failure placed the residents at risk for a non-homelike environment.

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of potential abuse and/or neglect of a fall with significant injury for 1 of 1 resident (Resident 30), was reported to the State Survey Agency. The failure to report as required resulted in the inability to recognize patterns of potential abuse and/or neglect with incidents of significant injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the residents' comprehensive assessment [(MDS) minimum data set, a standardized assessment tool that measures health status in nursing home residents)] regarding injectable anti-diabetic medications for 2 of 5 residents (Resident 32 and 49) reviewed for injectable medication. This failure placed the residents at risk for ineffective, inaccurate care plan interventions, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain and/or prevent a further decrease in range of motion [(ROM) - how far and in what direction you can move a joint or muscle] for a hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to rigidity of joints) for 1 of 3 residents (Resident 7) reviewed for restorative services. This failure placed the residents at increased risk for a worsening contracture, potential decrease in range of motion, and skin integrity issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate a referral for denture services for 1 of 2 residents (Resident 7) reviewed for dental services. This failure placed the residents at risk for altered self-image, difficulty eating, and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record related to dental services was accurate for 1 of 2 residents (Resident 18) reviewed for complete medical records. This failure had the potential risk for healthcare providers to rely on inadequate information when making treatment decisions for residents and a potential risk for not receiving quality care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representative were offered/educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) immunization (the action of taking a vaccine for a particular infectious disease) for 2 of 5 sampled residents (Residents 26 and 42) reviewed for immunization status. This failure placed the residents at risk of making an uninformed decision and contracting the COVID-19 virus.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, and sanitary (the conditions that affect hygiene and health) environment for residents and staff for 1 of 1 Laundry room (LR 1), reviewed for a comfortable environment. This failure placed residents and staff at risk for not feeling safe/secure with their environment and an increased risk of the cross contamination of diseases.

Inspectors wroteBased on interviews and record review the facility failed to complete a performance review at least once every 12 months as required, for 4 of 4 Nursing Assistants (NAs) (Staff B, C, D, E) reviewed for performance reviews. The failure to complete annual performance reviews placed residents at risk for unmet care needs from potentially unqualified staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to Identify and prevent potentially dangerous accidents and hazards when portable oxygen (02) tanks were unsecured for 2 of 2 residents (Resident 58 and 17) reviewed for O2 use, and implement interventions that addressed the cause of the falls for 1 of 2 residents (Resident 29) reviewed for falls. This placed Resident 29 at risk for future falls, injury and unmet care needs. The failure to secure portable O2 tanks which could explode if dropped placed Resident 58, Resident 17, and residents and anyone else in the facility at risk for serious injury, harm or death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure visitation rights were protected when they did not allow or advocate for the resident's choice in their decision making when the Resident's Representative (RR) denied them access for eight days, to their significant other (SO) and their SO's family member, for 1 of 3 residents (Resident 32), reviewed for choices. Resident 32 experienced psychological harm when they became angry, had a decreased appetite, and refused care when they were denied visitation with their SO.

Inspectors wroteBased on interview and record review, the facility failed to provide dietary services that met individualized dietary needs for 1 of 1 resident (Resident 64), reviewed for specialized diets. Resident 64 was on a physician ordered, gluten-free diet (no wheat, barley, or rye) related to a diagnosis of celiac disease (a disease that causes inflammation of the intestines if gluten is ingested). Resident 64 was served gluten in the form of a Salisbury steak on 12/24/2023. This failure caused harm to Resident 64 who experienced dizziness, nausea, and shortness of breath after consuming the gluten. Resident 64's change in condition resulted in physician notification and enhanced monitoring of their condition to ensure their safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure registry verification had been completed to show an individual met competency evaluation requirements for 3 of 3 Nursing Assistants (NA, Staff M, O, and R), reviewed for staff qualifications. This failed practice placed residents at risk of unmet care needs and abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services in a manner that maintained and promoted dignity for 2 of 2 residents (Residents 13 and 45) reviewed for resident rights. The facility failed to ensure resident dignity while dining, when Resident 13 was served their meals on disposable cutlery/dishware, and provide an environment that enhanced Resident 45's quality of life when their toilet was not working properly. These failures placed the residents at risk for humiliation and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clinical appropriateness for safe, self-administration of medication for 1 of 1 resident (Resident 45), reviewed for medication administration. Additionally, the facility failed to obtain a physician's order for the self-administration of the medications for the resident and did not update the individualized care plan. The failure to complete a self-administration assessment and obtain a physician's order placed the resident at risk for adverse medication reaction and a significant medication error.

Inspectors wroteBased on interview, and record review, the facility failed to ensure funds were reimbursed to the State Office of Financial Recovery (OFR), within 30 days of a resident's discharge or death, for 1 of 4 residents (Resident 119), reviewed for personal funds. This failed practice caused delay in the reconciliation of Resident 119's account within a 30-day period as required.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans prepared by the required members of the interdisciplinary team (IDT a group of healthcare providers from different fields who work together for the best outcome for residents) for 3 of 3 residents (Residents 51, 66, and 35) reviewed for comprehensive care planning. This failure placed the residents at risk of unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services for showers and personal hygiene needs for 3 of 3 residents (Resident's 29, 39, and 53) reviewed for Activities of Daily Living (ADLs). This failed practice placed residents at risk for unmet care needs and a undignified existence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care, services and documentation were provided in accordance with professional standards of practice for 2 of 3 residents (Residents 66 and 64) reviewed for quality of care. This failure placed the residents at risk for unmet care needs and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of care regarding catheter care and placement for 1 of 1 resident (Resident 54), reviewed for urinary tract infections (UTI). This failed practice put the resident at increased risk for infection.

Inspectors wroteBased on interview and record review the facility failed to implement an effective Water Management Program to safeguard the residents from exposure to potentially contagious water-borne diseases such as Legionella (a severe respiratory disease). This failed practice put the residents at risk of exposure to airborne infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary and homelike environment by not providing clean and sanitized wheelchairs for 2 of 2 residents (Residents 8 and 29), reviewed for environment. This failed practice put residents at risk for a undignified existence and infections.

Inspectors wroteBased on interview and record review the facility failed to notify the resident's representative of changes in condition in a timely manner for 1 of 4 residents (Resident 1) reviewed for notification of changes. The failure to timely notify the representative placed the resident at risk of not having their representative involved in the health care decision making process for timely care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement measures to prevent the spread of communicable disease during a COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak relative to the use of personal protective equipment (PPE), hand hygiene, COVID-19 testing and medication administration involving 1 of 1 Licensed Nurses (Staff A). This failure placed residents at risk for facility acquired or healthcare associated infections and related complications.

Inspectors wroteBased on interview and record review the facility failed to ensure persons providing care to residents had the appropriate nursing assistant credential for 1 of 3 provider staff (Staff A), reviewed for licensure. Failure to ensure care providers had an active license placed residents at risk for unmet care needs and/or poor quality of care.